1. The Prescribing Pyramid
Pyramids – The pyramids at Giza
Under a CC BY-NC-SA 2.0 license
Facilitators notes
This activity has 2 sections:
This presentation on the prescribing pyramid (1 hour)
The activity (1.5 hours)
Target audience
Nurses
Midwives
Pharmacists
Chiropodists
Physiotherapists
Junior doctors or medical students
Good prescribing is not easy I hope that this session will help you with you prescribing decisions. The process of writing a prescription starts a chain reaction that will have an impact on the patient, possibly their family, the prescriber and the NHS.
Kimberley Tordoff

2. Aim of the session
To appraise the use of the prescribing pyramid in relation to non medical prescribing decisions

3. Learning Outcomes By the end of the session learners will be able to
Knowledge
Describe the seven principles of good prescribing
Describe the concept of the prescribing pyramid
Skills
practice using the prescribing pyramid
challenge other members of the multi-disciplinary group on decisions
Attitudes
Continue to build up relationships with their peers through group work

4. The prescribing pyramid
Reflect
Record Keeping
Review
Negotiate a contract
Choice of product
Which strategy
Consider the patient
The process to prescribe or not to prescribe is a complex one that needs many factors considering before that all important piece of paper is given to the patient, the prescribing pyramid is a process that may help you so that you are sure all the bases have been covered.

6. 1. Consider the patient… The Consultation
Prepare as much as you can & establish rapport
Identify reasons for consult
Explore the patients
Ideas,
Concerns and
Expectations of the problem (ICE)
Obtain essential information
Impact of problem of the problem
Differential diagnoses
Re evaluate information, ensure shared understanding, consider more tests, and interpret results for diagnosis
Decide treatment options discuss with patient, Q&A
Summarising, terminating the consultation, writing-up
In 70% of cases the diagnosis will be evident just from a clinical history alone before tests or examination takes place. A good history facilitates good prescribing. Each consultation should have a structure bit it shouldn’t be like a straitjacket These are the vital elements that need to be covered
Rapport..observe the pt s demeanour, put at ease, convey warmth and confidence. In reality we don’t take a history we make a history as it is a two way process.

7. 1. Consider the patient WWHAM! What's Wham got to do with it?
Who is it for
What are the symptoms
How long have the symptoms been present
Any action taken
Medication
What information would you want to know about the patient/symptoms
NMC picked up on this mnemonic as it had been used by pharmacists when helping them advise people buy medications. It isn’t robust enough to use in isolation, but if incorporated into the assessment it makes sure that medication history is taken; POMs, OTC, Herbal, allergies, patients tend not to tell you about these as they don’t think that they are important. Examine the holistic needs of the patient looking at the determinants of health. Patients will often omit to tell you about OTC preps or herbal meds, but need to know for contraindicated drugs. Discuss illegal drug meds

8. The determinants of Health
Age, sex, hereditary factors
Lifestyle factors
Social & community networks
Living & working conditions
Socio-economic, cultural & environmental conditions
Dahlgren & Whitehead 1991
The pts medical and social history needs to be taken, a thorough needs assessment may show that non drug therapy may be indicated. Allergies need to be identified and recorded

9. Medications Drug History and Allergies
Ask patient to list medications they are on, or show their repeat prescription, or bring in their meds.
Ensure you have a written record in your notes of the name, dose, frequency and route.
Are they actually taking them as prescribed?
Enquire about Over The Counter (OTC), herbal and illicit…you may be shocked!
Any allergies or reactions to meds or foods or environmental factors and record them and any treatment given.
Really important part of prescribing
Patients symptoms may be as a result of the medications they are on!
Women often do not volunteer the pill as they don’t see it as medication
They may also not include inhalers, creams, patches or pessaries, eye drops….ask specifically

10. 2. Strategy Is diagnosis established? Is there a need to prescribe?
Is referral elsewhere indicated?
What does the patient expect?
A prescription should only be given when there is a genuine need. When the patient presents it is important to bear in mind that other treatment options need to be considered. Only prescribe when there is a genuine need, patients may want to have a prescription for other reasons…legitimate a sick role, a friend recommended it, gain attention, give or sell to someone else. Patient expectations for medication. Could there be alternative treatments… TENS
Has the pt presented with serious or sinister signs that need attention from another person

11. 3. Choice Appropriate Effective Safe Cost Acceptable
“Sign," © 2011 Adam Williams, Used under a Creative Commons Attribution-Non-commercial-ShareAlike 2.0 Generic license:

12. Safety Issues
For any given therapeutic intervention, the potential benefits of the treatment must always be balanced against the known safety concerns.
ADRs account for 5% of all hospital admissions and are associated with significant M and M risks

13. Avoiding Adverse Drug Reactions
Use as few concurrent drugs as possible
Use the lowest effective dose
Check if patient pregnant or breast feeding
Is the patient at extremes of life?
Do you know all of the drugs that the patient is taking
Check for Over The Counter medicines
Drug allergies or previous reactions to medications

14. 4. Negotiate Concordance Compliance Medicines adherence
DANCING NOT FIGHTING! Enables the pt to have a role in the decision making process. . It is a shared contract between the prescriber and patient. It replaces the term compliance which is seen as a negative concept where the patient simply does as they are told.
For concordance to occur the patient needs to know what the drug is for, side effects, how long it takes to work, efficacy, when to get advice and from where, potential problems and what to do needs to be talked through with the patient. Patient leaflets.
Add image of handshake and dancers

15. Review Where When How Who
Regular review of the patient will establish whether the meds prescribed is safe and effective and acceptable. Always have a plan B
Policy on repeat prescriptions variable, repeat prescribing without review will be wasteful and potentially dangerous. make sure the pt knows who to contact and when

16. Record Why is it important What are the barriers to this in practise
Good records are essential, a professional requirement from the NMC enter prescription details into records asap in the appropriate records, best practice 24 hours in community to amend gp records
Include date, name of prescriber, name of drug, in fact everything that is on the script plus a record of the consult. Your records need to support your decision making process in case of legal comeback, but also to help fellow clinicians in future evaluation of the patient.

17. Record Keeping Guidelines
Accurate
Legible
Unambiguous
Contemporaneous
Relevant
Enough to enable other professionals to provide effective care
Dated, timed and signed
Practitioners must not tamper with original records in any way
Electronic records are clearly attributable
Kept securely (NMC,2008)
Integral part of professional practice
Is not an optional extra to be omitted if you are short of time
Is a reflection of your standard of practice

18. Reflect On your prescribing decision On the episode as a whole
Discuss with colleagues
Code of conduct states that we should maintain and improve our professional knowledge and competence and by reviewing and reflecting we can do this almost on a subliminal level after a while. Periodic review with co workers, discuss with pharmacy, pact data prescribing analysis and cost…allows the individual to compare with others and whether you adhere to local policies

19. References
Dahlgren & Whitehead (1991) Social Model of Health Nursing & Midwifery Council ( NMC) (2008) The code: Standards of conduct, performance and ethics for nurses and midwives May London NMC

20. Note for facilitator Divide the class into inter-professional groups
Now proceed to Activity on prescribing pyramid

21. This work was produced as part of the TIGER project and funded by JISC and the HEA in For further information see:
This work by TIGER Project is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 3.0 Unported License. Based on a work at tiger.library.dmu.ac.uk.
The TIGER project has sought to ensure content of the materials comply with a CC BY NC SA licence. Some material links to third party sites and may use a different licence, please check before using. The TIGER project nor any of its partners endorse these sites and cannot be held responsible for their content. Any logos or trademarks in the resource are exclusive property of their owners and their appearance is not an endorsement by the TIGER project.